PRIVACY ACT MATERIAL REMOVED
GOVERNMENT OF THE MARSHALL ISLANDS
Majuro, Marshall Islands
Special Health Survey
Name
oe
|
-
Sex
AA
Age [7
Residence:
1954-1960 — /bATALO
1960-1966 —~ Lu —
1966-1972, ee
1972Det
Snort description of symptoms:
EXE Ae OAH ES7
Surgery
Ste LIV ESS
‘F
EK ERIAA z
:
ay cide[meg
Year
JP7
Have you been receiving treatment for any illness for a peric.s
over one year?
VS,
Has anyone in your family complained of similar symptoms to ene
ones you are now experiencing? LE Nie
Surgery?
NMOL
ay
Signature
|
a
oo
B501112
Date
Le
5
Hai
ff #-
PRIVACYACT MATERIAL REMOVED